Comprehensive Assessment: Tina Jones

Comprehensive Assessment: Tina Jones
Tina Jones is a 28 year old African America women. She came into the clinic for
a physical exam.
She is starting a new job as an accounting clerk at Smith, Stewart, Silver & Company. She is required to
have a physical exam for her health insurance. Tina's health history was taken, a physical
assessment was done and a plan of care was made.
Health History
Health history is a very important part of assessment for practitioners. When
interviewing the patient the practitioner is able to get a health history and the history of
the patients chief complaint. Through the interview process the practitioner is als
o able to find out what the patient believes is most important about their health (Bickley, 2013).
Tina is a 28 year old African American women. She is in the clinic today for a physical
exam for her new job. She is the primary source of health history. Tina's speech
is clear and coherent. She maintains eye contact throughout the interview. Tina is alert
and oriented. She is well-developed and dress appropriately with good hygiene.
She does not appear to be in any distress.
Tina is allergic to cats, she states that she tries to avoid cats but when she is around them her
asthma "acts up" (T. Jones, Shadow Health Interview, February 13, 2016). She states that she
has tightness in her chest and wheezing. She is allergic to PCN. She states that she "got a ra
sh, like hives" after taking PCN (T. Jones, Shadow Health Interview, February 13, 2016). She
denies any food and latex allergies. She denies having any recent allergies to dust or pol
len. She states that she has had problems in the past but they have not h
appened in "a while" (T. Jones, Shadow Health Interview, February 13, 2016). She states that
her daily inhaler has helped with her environmental allergies.
Tina has been diagnosed with diabetes, asthma and polycystic ovarian syndrome (PCOS).
Tina was diagnosed with Diabetes at age 24. Tina checks her blood sugar once a day, in the
morning. Her diabetes is being treated with metformin 850 mg PO BID. She has changed her
diet recently to help with her diabetes. She limits her carbohydrates and avoids sugar. Tina was
diagnosed with asthma at age 2 1/2. She is treating her asthma with a daily inhaler as well as
a rescue inhaler. Her daily inhaler is Flovent 88mcg/spray MDI 2 puff BID. Her rescue inhaler is
90 mcg/spray MDI 2 puff PRN for shortness of breath. She states that her daily inhaler has
improved her asthma. She states that her last asthma attack was 3 months ago. She states that
when she has an attack her chest feel tight and she has wheezing. She states that it feels like
she "cant' get enough air”. Her last asthma related hospitalization was when she was 16. She
states that her asthma is worst when around cats but she also has problems with dust and
running up stairs. Tina was recently diagnosed with
PCOS
.
Her OB/GYN started her on Yaz birth
control to treat the PCOS. The
Yaz
is
being used to co
ntrol
and lessen symptoms of
PCOS.
She has noticed that her periods are more regular
and her cramps are not "as bad
"
(T.